Sending

Likely, you are most aware of verbal communication—the words you speak, vocalisations, the tone of voice. Nonverbal communication also occurs. This is your body language—posture, body gestures such as foot tapping, facial expression, eye contact, touch, even where you place your chair. Since nonverbal communication is under less conscious control than verbal communication, nonverbal communication probably is more reflective of your true feelings.

Receiving

Being aware of the messages you send is only part of the process. Your words and gestures must be interpreted in a specific context to have meaning. You have a specific context in mind when you send your words. The receiver puts their own interpretation on them. The receiver attaches meaning determined by their past experiences, culture and self-concept, as well as current physical and emotional state. Sometimes, however, the contexts of the sender and receiver do not coincide. Remember how frustrating it may have been to try to communicate something to a friend, only to have your message totally misunderstood? Your message can be sabotaged by the listener’s bias. It takes mutual understanding by the sender and receiver to have successful communication.

Even greater risk for misunderstanding exists in the healthcare setting than in a social setting. The patient usually has a health problem, and this factor emotionally charges your professional relationship. It intensifies the communication because the person feels dependent on you to correctly interpret their messages.

Communication is a fundamental skill that can be learned and polished when you are a beginning practitioner. It is a tool, as intrinsic to quality healthcare as the tools of inspection or palpation. To maximise your communicating skill, first you need to be aware of internal factors (personal qualities and abilities) and external factors (environmental and other issues) and their influence.

Internal factors (personal qualities and abilities)

Internal factors are those particular to the examiner, what you bring into the interview. Cultivate the three inner factors of liking others, empathy and the ability to listen.

External factors (environmental and other issues)

Preparation of the physical setting where the interview is to occur is essential. The setting may be in a hospital room, an examination room in an office or clinic or in the person’s home (where you will have less control). In any location, optimal conditions are important to have a smooth interview. Therefore, preparation of the physical setting must include attention to the following elements:

Ensure privacy.

Aim for geographic privacy—a private room in the hospital, clinic, office or home. This may involve asking an ambulatory roommate to step out for a while or finding an unoccupied room or an empty lounge. If geographic privacy is not available, ‘psychological privacy’ by curtained partitions may suffice as long as the person feels sure no one can overhear the conversation or interrupt.

Refuse interruptions.

Most people resent interruptions except in cases of an emergency. Inform any support staff of your interview, and ask that they not interrupt you during this time. Discourage other health professionals from interrupting you with their need for access to the patient. You need to concentrate and to establish rapport. An interruption can destroy in seconds what you have spent many minutes building up.

Physical environment

• Set the room temperature at a comfortable level.

• Provide sufficient lighting so that you can see each other clearly. Avoid facing the patient directly towards a strong light where the patient must squint as if on stage.

• Reduce noise. Multiple stimuli are confusing. Turn off the television, radio and any unnecessary equipment.

• Remove distracting objects or equipment. It is appropriate to leave some professional equipment (blood pressure manometer) in view. However, clutter, stacks of mail, files of other patients or your lunch should not be seen. The room should advertise the professional nature of the interviewer.

• Place the distance between you and the patient at 1 to 1.5 metres (twice arm’s length). If you place the patient any closer, you may invade their private space and you may create anxiety. If you place the patient further away, you seem distant and aloof. (See Cultural and Social Considerations below for more information.)

• Arrange equal-status seating. Both you and the patient should be comfortably seated, at eye level. Avoid facing a patient across a desk or table because that feels like a barrier. Placing the chairs at 90 degrees is good because it allows the person either to face you or to look straight ahead from time to time (Fig 6.1). Most important, avoid standing. Standing does two things: (1) it communicates your haste, and (2) it assumes superiority. Standing makes you loom over the patient as an authority figure. When you are sitting, the person feels some control in the setting.

• Arrange a face-to-face position when interviewing the hospitalised bedridden person. The person should not have to stare at the ceiling, because this causes them to lose the visual message of your communication.

Figure 6.1 Equal-status seating.

Dress

• The patient should remain in their own clothes except in the case of an emergency.

• Your appearance and clothing should be appropriate to the setting and should meet conventional professional standards including conservative clothing, a name tag and neat hair. Avoid extremes.

Note-taking.

Some use of history forms and note-taking may be unavoidable. When you sit down later to record the interview, you cannot rely completely on memory to furnish details of previous hospitalisations or the review of body systems, for example. But be aware that note-taking during the interview has disadvantages:

• It breaks eye contact too often.

• It shifts your attention away from the person, diminishing their sense of importance.

• It can interrupt the patient’s narrative flow. You may say ‘Please slow down; I’m not getting it all’. Or, the patient may see you recording furiously, and in an effort to please you, adjust their tempo to your writing. Either way, the patient’s natural mode of expression is lost.

• It impedes your observation of the patient’s nonverbal behaviour.

• It is threatening to the patient during the discussion of sensitive issues (e.g. amount of alcohol and drug use, number of sexual partners, or incidence of physical abuse).

So keep note-taking to a minimum, and try to focus your attention on the person. Any recording you do should be secondary to the dialogue and should not interfere with the person’s spontaneity. With experience, you will not rely on note-taking as much.

Introducing the interview

The patient is here and you are ready for the interview. If you are nervous about how to begin, remember to keep the beginning short. Probably, the patient is nervous, too, and is anxious to start. Address the person, using their surname, and shake hands if that seems comfortable. Introduce yourself and state your role in the organisation (if you are a student, say so). If you are gathering a complete history, give the reason for this interview:

If the person is in the hospital, more than one health team member may be collecting a history. Patients are apt to feel exasperated because they believe they are repeating the same thing unless you give a reason for this interview.

After this brief introduction, ask an open-ended question (see below) then let the person proceed. You do not need friendly small talk to build rapport. This is not a social visit; the person has some concern to talk about and wants to get on with it. You will build rapport best by letting them discuss the concern early.

The working phase

The working phase is the data-gathering phase. Verbal skills for this phase include your questions to the patient and your responses to what the patient has said. Two types of questions exist: open-ended and closed. Each type has a different place and function in the interview.

The patient’s frame of reference

Facilitation.

These responses encourage the patient to say more, to continue with the story (‘mm-hmm, go on, continue, uh-huh’). Also called general leads, these responses show the person you are interested and will listen further. Simply maintaining eye contact, shifting forwards in your seat with increased attention, nodding ‘Yes’ or using your hand to gesture ‘Yes, go on, I’m with you’ encourages the person to continue talking.

Silence.

Silence is golden after open-ended questions. Your silent attentiveness communicates that the patient has time to think, to organise what they wish to say without interruption from you. This ‘thinking silence’ is the one health professionals interrupt most often. The interruption destroys the person’s train of thought. The patient is often interrupted because silence is uncomfortable to beginning examiners. They feel responsible for keeping the dialogue going and feel at fault if it stops. But silence has advantages. One advantage is letting the person collect their thoughts. Also, silence gives you a chance to observe the person unobtrusively and to note nonverbal cues. Finally, silence gives you time to plan your next approach.

Reflection.

This response echoes the patient’s words. Reflection is repeating part of what the person has just said. In this example, it focuses further attention on a specific phrase and helps the person continue in their own way:

Patient: I’m here because of my water. It was cutting off.

Response: It was cutting off?

Patient: Yes, yesterday it took me 30 minutes to pass my water. Finally I got a tiny stream, but then it just closed off.

Reflection also can help express feeling behind a person’s words. The feeling is already in the statement. You focus on it and encourage the person to elaborate:

Patient: It’s so hard having to stay flat on my back in the hospital with this pregnancy. I have two more little ones at home. I’m so worried they are not getting the care they need.

Response: You feel worried and anxious about your children?

Think of yourself as a mirror reflecting the person’s words or feelings. This helps the person to elaborate on the problem.

Empathy.

A physical symptom, condition or illness often has accompanying emotions. Many people have trouble expressing these feelings, perhaps because of confusion or embarrassment. In the second reflecting example above, the person already had stated her feeling and you echoed it. But in the first example, he has not said it yet. An empathic response recognises a feeling and puts it into words. It names the feeling and allows the expression of it. When the empathic response is used, the patient feels accepted and can deal with the feeling openly.

Patient (sarcastically): This is just great. I have my own business, I direct 20 employees every day, and now here I am having to call you for every little thing.

Response: It must be hard—one day having so much control, and now feeling dependent on someone else.

Your response does not cut off further communication as would happen by giving false reassurance (‘Oh, you’ll be back to work in no time’). Also, it does not deny the feeling and indicate that it is not justified (‘Now I don’t do everything for you. Why, you are feeding yourself’). An empathic response recognises the feeling, accepts it and allows the person to express it without embarrassment. It strengthens rapport. The patient feels understood, which by itself is therapeutic, because it opens the isolation of illness. Other empathic responses are, ‘This must be very hard for you’, ‘I understand’ or just placing your hand on the person’s arm (Fig 6.2).

Figure 6.2

Clarification.

Clarify what a person means when their word choice is ambiguous or confusing; for example, ‘Tell me what you mean by tired blood’. You can also use clarification to summarise the person’s words, or simplify them to make them clearer. Confirm with the patient/client that you are on the right track: you are asking for agreement, and the person can confirm or deny your understanding.

Response: Now as I understand you, this heaviness in your chest comes when you mow the lawn or climb stairs, and it goes away when you stop doing those things. Is that correct?

Patient: Yes, that’s pretty much it.

Ten traps of interviewing

The verbal skills discussed above are productive and enhance the interview. Now take time to consider nonproductive, defeating verbal messages, or traps. It is easy to fall into these traps because you are anxious to help. The danger is that they restrict the patient’s response. The following traps are obstacles to obtaining complete data and to establishing rapport.

1 Providing false assurance or reassurance.

A woman says, ‘Oh I just know this lump is going to turn out to be cancer’. What happens inside you? The automatic response of many clinicians is to say, ‘Now don’t worry; I’m sure you will be all right’. This ‘courage builder’ relieves your anxiety and gives you the false sense of having provided comfort. But for the woman it actually closes off communication. It trivialises her anxiety and effectively denies any further talk of it. (Also it promises something that may not happen—that is, she may not be all right.) Consider instead these responses:

‘You are really worried about the lump, aren’t you?’

‘It must be hard to wait for the biopsy results.’

These responses acknowledge the feeling and open the door for more communication.

A genuine, valid form of reassurance does exist. You can reassure patients that you are listening to them, that you understand them, that you have hope for them and that you will take good care of them.

Patient: I feel so lost here since they transferred me to the medical centre. No one comes to see me. No one here cares what happens to me.

Response: I care what happens to you. I am here today and I want you to know that I’ll be here all week.

This type of reassurance makes a commitment to the patient, and it can have a powerful impact.

2 Giving unwanted advice.

Know when to give advice and when to avoid giving it. Often, people seek healthcare because they want your professional advice and information on the management of a health problem: ‘My child has chickenpox; how should I take care of him?’ This is a straightforward request for information you have that the parent needs. You respond by giving a health prescription, a therapeutic plan based on your knowledge and experience.

In other situations, advice is different; it is based on a hunch or feeling. It is your personal opinion. Consider the woman who has just left a meeting with her consultant physician: ‘Dr Kline just told me my only chance of getting pregnant is to have an operation. I just don’t know. What would you do?’ Does the woman really want your advice? If you answer, ‘If I were you, I’d …’ then you would be making a mistake. You are not her. If you give your answer, you have shifted the accountability for decision making from her to you. She has not worked out her own solution. She has learned nothing about herself.

Does the woman really want to know what you would do? Probably not. Instead, a better response is reflection:

Response: Have an operation?

Woman: Yes, and I’m terrified of being put to sleep. What if I don’t wake up?

Now you know her real concern and can help her deal with it. She will have grown in the process and may be better equipped to meet her next decision.

When asked for advice, other preferred responses are,

‘What are the pros and cons of ________ [this choice] for you?’

‘What concerns do you have?’

‘What is holding you back?’

Although it is quicker just to give advice, take the time to involve the patient in a problem-solving process. When a patient participates, they are more likely to learn and to change behaviour.

3 Using authority.

‘Your doctor/nurse knows best’ is a response that promotes dependency and inferiority. The communication pathway looks something like this:

with your talk coming ‘down’ and little from the patient going back ‘up’. A better approach is to avoid using authority. Although you and the patient cannot have equality of professional skill and experience, you do have equally worthy roles in the health process, each respecting the other.

4 Using avoidance language.

People use euphemisms such as ‘passed on’ to avoid reality or to hide their feelings. They think if they just say the word ‘death’, it might really happen. So to protect themselves, they evade the issue. Although it seems this will make comfortable potentially fearful topics, it does not. Not talking about the fear does not make it go away; it just suppresses the fear and makes it even more frightening. Using direct language is the best way to deal with frightening topics.

5 Engaging in distancing.

Distancing is the use of impersonal speech to put space between a threat and the self: ‘My friend has a problem; she is afraid she …’ or ‘There is a lump in the left breast’. By using ‘the’ instead of ‘my’, the woman can deny any association with her diseased breast and protect herself from it. Health professionals use distancing, too, to soften reality. This does not work because it communicates to the other person that you also are afraid of the procedure. The use of blunt specific terms is actually preferable to defuse anxiety.

6 Using professional jargon.

What is called a myocardial infarction in the health profession is called a heart attack by most laypeople. Use of jargon sounds exclusionary and paternalistic. You need to adjust your vocabulary to the person, but avoid sounding condescending.

If a patient uses medical jargon, do not assume they always know the correct meaning. For example, some people think ‘hypertensive’ means that they are very tense. As a result, they take their medication only when feeling stressed and not when they feel relaxed. This misinformation must be corrected. They need to understand that hypertension is a chronic condition that needs consistent medication to avoid side effects. On the other hand, you do not need to feel that it is a moral imperative to correct all misstatements (e.g. when a patient says ‘prostrate’ for prostate gland).

7 Using leading or biased questions.

Asking a man, ‘You don’t smoke, do you?’ implies that one answer is ‘better’ than another. If the person wants to please you, either he is forced to answer in a way corresponding to your values or he feels guilty when he must admit the other answer. He risks your disapproval. And if he feels dependent on you for care, the last thing he wants to do is alienate you.

8 Talking too much.

Some examiners positively associate helpfulness with verbal productivity. If the air has been thick with their oratory and advice, these examiners leave thinking they have met the patient’s needs. Just the opposite is true. Anxious to please the examiner, the patient lets the professional talk at the expense of their need to express themself. A good rule for every interviewer is to listen more than you talk.

9 Interrupting.

Often, when you think you know what the person will say, you interrupt and cut the person off. This does not show that you are clever. Rather, it signals that you are impatient or bored with the interview.

A related trap is preoccupation with yourself by thinking of your next remark while the person is talking. The communication pathway looks like this:

As the patient speaks, you are thinking about what to say next. Thus you cannot fully understand what the person says. You are so preoccupied with your own role as the interviewer that you are not really listening. Aim for a second of silence between the person’s statement and your next response. Ideally, your communication pathway should look like this:

with two people talking, and two people listening.

10 Using ‘why’ questions.

A young child asks, ‘Why does the moon look like the end of my fingernail?’ The motive behind this question is an innocent search for information. This is quite different from that of an adult’s ‘why’ question, such as ‘Why were you so late for your appointment?’ The adult’s use of why questions usually implies blame and condemnation; it puts the person on the defensive.

Consider your use of why questions in the healthcare setting. ‘Why did you take so much medication?’ Or, let’s say you ask a man who has just come to the emergency department, ‘Why did you wait so long before coming to the hospital?’ The only possible answer to a why question is ‘because …’ and the man may not know the answer. He may not have worked it out. You sound whining, accusatory and judgmental. And the man now must produce an excuse to rationalise his own behaviour. To avoid this trap, say: ‘I see you started to have chest pains early in the day. What was happening between the time the pains started and the time you came to the emergency department?’

Nonverbal skills

Learn to listen with your eyes as well as with your ears. Nonverbal modes of communication include physical appearance, posture, gestures, facial expression, eye contact, voice and touch. Nonverbal messages are very important in establishing rapport and in conveying information, especially about feelings. Nonverbal messages provide clues to understanding feelings. When nonverbal and verbal messages are congruent, the verbal is reinforced. When they are incongruent, the nonverbal message tends to be the true one, because it is under less conscious control.

Closing the interview

The session should end gracefully. An abrupt or awkward closing can destroy rapport and leave the person with a negative impression of the whole interview. To ease into the closing, ask the person:

This gives the person the final opportunity for self-expression. Then, to indicate that closing is imminent, say something like ‘Our interview is just about over’. No new topic should be introduced now. This is a good time to give your summary of what you have learned during the interview. The summary is a final statement of what you and the patient agree the health state to be. It should include positive health aspects, any health problems that have been identified, any plans for action or an explanation of the following physical examination. As you part from patients, thank them for the time spent and for their cooperation.

Interviewing the parent

When your patient is a child, you must build rapport with two people—the child and the accompanying parent. Greet both by name, but with a younger child (1 to 6 years old), focus more on the parent. By ignoring the child temporarily, you allow the child to size you up from a safe distance. The child can observe your interaction with the parent, see that the parent accepts and likes you, and relax (Fig 6.3).

Figure 6.3

Begin by interviewing the parent and child together. If any sensitive topics arise (e.g. the parents’ troubled relationship or the child’s problems at school or with peers), explore them later when the parent is alone. Provide toys to occupy the child as you and the parent talk. This frees the parent to concentrate on the history. Also, it indicates the child’s level of attention span or independent play. Through the interview, be alert to ways the parent and child interact.

For younger children, the parent will provide all or most of the history. Thus you are collecting the child’s health data from the parent’s frame of reference. Usually, this viewpoint is reliable because most parents have the child’s wellbeing as a priority and see cooperation with you as a way to enhance this wellbeing. But the possibilities exist for parental bias. Bias can occur when parents are asked to describe the child’s achievements, or whenever their own parenting ability seems called into question. For example, if you say ‘His fever was 39.5°C and you did not bring him in?’ you are implying a lack of parenting skill. This puts the parent on the defensive and increases anxiety. Instead, use open-ended questions that increase description and defuse threat, such as ‘What happened when the fever went up?’

A parent with more than one child has more than one set of data to remember. Be patient as the parent sorts through their memory to pull out facts of developmental milestones or past history. A comprehensive history may be lacking if the child is accompanied by a family friend or day care provider instead of the parent.

In collecting developmental data, avoid being judgmental about the age of achievement of certain milestones. Parents are understandably proud of their child’s achievements and are sensitive to inferences that these milestones may occur late.

Refer to the child by name—not as ‘the baby’. Refer to the parent by name, and not the demeaning ‘Mother’ or ‘Dad’. Also, be clear when identifying the parents. The mother’s present husband may not necessarily be the child’s father. Instead of asking about ‘your husband’s health’, ask ‘Is Joan’s father in good health?’

Although most of your communication is with the parent, do not ignore the child completely. You need to make contact to ease into the physical examination later. Begin by asking about the toys the child is playing with or about a special doll or teddy bear brought from home: ‘Does your doll have a name?’ or ‘What can your truck do?’ Stoop down to meet the child at their eye level. Adult size can be overwhelming to young children and can emphasise their smallness.

Nonverbal communication is even more important to children than it is to adults. Children are quick to pick up feelings, anxiety or comfort from nonverbal cues. Keep your physical appearance neat and clean, and avoid formal uniforms that distance you. Keep your gestures slow, deliberate and close to your body. Children are frightened by quick or grandiose gestures. Do not try to maintain constant eye contact; this feels threatening to a small child. Use a quiet, measured voice, and choose simple words in your speech. Considering the child’s level of language development is valuable in planning your communication.

The infant

Nonverbal communication is the primary method. Most infants look calm and relaxed when all their needs are met, and they cry when they are frightened, hungry, tired or uncomfortable. They respond best to firm, gentle handling and a quiet, calm voice. Your voice is comforting, even though they do not understand the words. Older infants have anxiety towards strangers. They are more cooperative when the parent is kept in view.

The preschooler

A 2- to 5-year-old is egocentric. They see the world mostly from their own point of view. Everything revolves around them. It may not work to cite the example of another child’s behaviour to get the child to cooperate. It has no meaning. Only the child’s own experience is relevant.

Preschoolers’ communication is direct, concrete, literal and set in the present. Avoid expressions such as ‘climbing the walls’, because they are easily misinterpreted by young children. Use short, simple sentences with a concrete explanation. Take time to give a short simple explanation for any unfamiliar equipment that will be used on the child. Preschoolers can have animistic thinking about unfamiliar objects. They may imagine that unfamiliar inanimate objects can come alive and have human characteristics (e.g. that a blood pressure cuff can wake up and bite or pinch).

The school-age child

A child 5 to 12 years old can tolerate and understand others’ viewpoints. This child is more objective and realistic. They want to know functional aspects—how things work and why things are done.

Children of this age group have the verbal ability to add important data to the history. Interview the parent and child together, but when a presenting symptom or sign exists ask the child about it first, then gather data from the parent. For the well child seeking a checkup, pose questions about school, friends or activities directly to the child.

The pre-adolescent/adolescent (12–19 years)

Adolescents want to be adults, but they do not have the cognitive ability yet to achieve their goal. They are between two stages. Sometimes they are capable of mature actions, and other times they fall back on childhood response patterns, especially in times of stress. You cannot treat adolescents as children, yet you cannot overcompensate and assume that their communication style, learning ability and motivation are consistently at an adult level.

Adolescents value their peers. They crave acceptance and sameness with their peers. Adolescents think no adult can understand them. Because of this, some act with aloof contempt, answering only in monosyllables. Others make eye contact and tell you what they think you want to hear, but inside they are thinking ‘You’ll never know the full story about me’.

This knowledge about adolescents is apt to paralyse you in communicating with them. However, successful communication is possible and rewarding. The guidelines are simple.

The first consideration is your attitude, which must be one of respect. Respect is the most important thing you can communicate to the adolescent. The adolescent needs to feel validated as a human being, is accepted and worthy.

Second, your communication must be totally honest. The adolescent’s intuition is highly tuned and can detect phoniness or when information is withheld. Always give them the truth. Play it straight or you will lose them. They will cooperate if they understand your rationale.

Stay in character. Avoid using language that is absurd for your age or professional role. It is helpful to understand some of the jargon used by adolescents, but you cannot use those words yourself simply to try to bond with the adolescent. Do not try to be their peer. You are not, and they will not accept you as such.

Use icebreakers. Focus first on the adolescent, not on the problem. Although an adult just wants to get on with it and talk about the health concern immediately, the adolescent responds best when the focus is on them as a person. Show an interest in the adolescent. Ask open, friendly questions about school, activities, hobbies and friends. Refrain from asking questions about parents and family for now—these issues can be emotionally charged during adolescence.

Do not assume adolescents know anything about a health interview or a physical examination. Explain every step and give the rationale. They need direction. They will cooperate when they know the reason for the questions or actions. Encourage their questions. Adolescents are afraid they will sound ‘dumb’ if they ask a question to which they assume everybody else knows the answer.

Keep your questions short and simple. ‘Why are you here?’ sounds brazen to you, but it is effective with the adolescent. Be prepared for the adolescent who does not know why they are there. Some adolescents are pushed into coming to the examination by a parent.

The communication responses described for the adult need to be reconsidered when talking with the adolescent. Silent periods are usually best avoided. Giving adolescents a little time to collect their thoughts is acceptable, but a silence for other reasons is threatening. Also, avoid reflection. If you use reflection, the adolescent is likely to answer, ‘What?’ They just do not have the cognitive skills to respond to that indirect mode of questioning. Also, adolescents are more sensitive to nonverbal communication than are adults. Be aware of your expressions and gestures. They are also more sensitive to any comment they take to mean criticism from you, and will withdraw.

Later in the interview, after you have developed rapport with the adolescent, you can address the topics that are emotionally charged, including alcohol and drug use, sexual behaviours, suicidal thoughts and depression. Adolescents will assume that health professionals have similar values and standards of behaviour as most of the other authority figures in their lives, and they may be reluctant to share this information. You can assure them that your questions are not intended to be curious or intrusive, but cover topics that are important for most teens and on which you have relevant health information to share.

If confidential material is uncovered during the interview, consider what can remain confidential and what you feel you must share for the wellbeing of the adolescent. State laws vary about confidentiality with minors, and in some states parents are not notified about, for example, birth control prescriptions or treatment for sexually transmitted infections (STIs). However, if the adolescent talks about an abusive home situation, state that you must share this information with other health professionals for their own protection. Ask the adolescent, ‘Do you have a problem with that?’ and then talk it through. Tell the adolescent, ‘You will have to trust that I will handle this information professionally and in your best interest’.

Finally, take every opportunity for positive reinforcement. Praise every action regarding healthy lifestyle choices: ‘That’s great that you don’t smoke. You get lots of gold stars in my book for staying off the cigarettes. It’s great for your heart, it will save you lots of money that you can use on other things and your skin won’t be wrinkled when you get older’.

The person over 65 years

The person over 65 has the developmental task of finding the meaning of life and the purpose of their own existence, and adjusting to the inevitability of death. Some people have developed comfortable and satisfying answers and greet you with a calm demeanour and self-assurance. Be alert for the occasional person who sounds hopeless and despairing about life at present and in the future. Symptoms of illness are even more frightening when they mean physical limitation or threaten independence.

Always address the person by the last name (e.g. ‘Hello, Mr Choi;’ ‘Good morning, Mrs Smith’). Some older adults resent being called by their first name by younger persons, and almost all cringe at the ignominious ‘Grandma’ or ‘Pop’.

The interview usually takes longer with people over 65 because they have a longer story to tell. You may need to break up the interview into more than one visit, collecting the most important historical data first. Or certain portions of the data, such as past history or the review of systems, can be provided on a form that is filled out at home, as long as the person’s vision and handwriting are adequate. Take time to review these parts with the person during the interview.

It is important to adjust the pace of the interview to the age of the person. People over 65 have a great amount of background material to sort through, and this takes some time. Also, some older persons need a greater amount of response time to interpret the question and process their answer. Avoid trying to hurry them along. This approach only affirms their stereotype of younger persons in general and healthcare providers in particular—that is, people who are merely interested in numbers of patients and filling out forms. Any urge from you to get on with it will surely make them retreat. You will lose valuable data and their needs will not be met.

Consider physical limitations when planning the interview. People over 65 may fatigue earlier and may require that the interview be broken up into shorter segments. For the person with impaired hearing, face directly so that your mouth and face are fully visible. Do not shout; it does not help and actually distorts speech.

Touch is a nonverbal skill that is very important to older persons. Their other senses may be diminished, and touch grounds you in reality. Also, a hand on the arm or shoulder is an empathic message which communicates that you empathise with the person and want to understand their problem (see Cultural and Social Considerations below for exceptions).

Hearing-impaired people

Although many people will tell you in advance that they have a hearing deficit, others must be recognised by clues, such as staring at your mouth and face, not attending unless looking at you or speaking in a voice unusually loud or with guttural or garbled sounds. The deaf person may be familiar with some equipment in the hospital or office setting or may have had previous experience with healthcare settings. But without full communication, the hearing-impaired person is sure to feel isolated and anxious. Ask what is their preferred way to communicate—by signing, lip reading or writing.

A complete health history requires a sign language interpreter. Since most healthcare professionals are not proficient in signing, try to find an interpreter through a social service agency or the person’s own social network. You may use family members, but be aware that they sometimes edit for the person. Use the same guidelines as for the bilingual interpreter (see Cultural and Social Considerations below).

If the person prefers lip reading, be sure to face them squarely and have good lighting on your face. Examiners with a beard, moustache or foreign accents are less effective. Do not exaggerate your lip movements because this distorts your words. Similarly, shouting distorts the reception of a hearing aid the person may wear. Speak slowly and supplement your voice with appropriate hand gestures or pantomime. Nonverbal cues are important adjuncts because the lip reader understands at best only 50% of your speech when relying solely on vision. Be sure the person understands your questions. Many hearing-impaired people nod ‘yes’ just to be friendly and cooperative but really do not understand.

Written communication is efficient in sections such as past health history or review of systems. For the present history of illness, writing is very time consuming and laborious. The syntax of the person’s written words will read normally if the hearing impairment occurred after speech patterns developed. If the deafness occurred before speech patterns developed, the written syntax follows that of signing, which is different from that of English.

Acutely ill people

An emergency demands your prompt action. You must combine interviewing with physical examination skills to determine lifesaving actions. Although life support measures may be paramount, still try to interview the person as much as possible. Subjective data are crucial to determine the cause and course of the emergency. Abbreviate your questioning. Identify the main area of distress and direct your questions to them. Family or friends can often provide important data.

A hospitalised person with a critical or severe illness is usually too weak, too short of breath or in too much pain to talk. First attend to the comfort of the person. Then establish a priority; find out immediately what parts of the history are the most relevant. Explore the first concern the person mentions. Begin to use closed, direct questions earlier. Finally, watch that your statements are very clear. When a person is very sick, even the simplest sentence can be misconstrued. The person will react according to preconceived ideas about what a serious illness means, so anything you say should be direct and precise.

People under the influence of non-prescription drugs or alcohol

It is common for persons under the influence of alcohol or other mood-altering drugs to be admitted to a hospital; all of these drugs affect the central nervous system, increasing the risk for accidents and injuries. Also, chronic use creates complex medical problems that require increasing care.

Many substance abusers are poly-drug abusers. You may be faced with a wide range of patient behaviours due to current influence. Alcohol, opioids (for example heroin) and central nervous system stimulants (for example, cocaine, ecstasy, amphetamines) can cause an intense high, agitation and paranoid behaviour. Hallucinogens cause bizarre, inappropriate, sometimes even violent behaviour accompanied by superhuman strength and insensitivity to pain.

When interviewing a person currently under the influence of alcohol or non-prescription drugs, ask simple and direct questions. Take care to make your manner and questions nonthreatening. Avoid confrontation at this point. Further, avoid any display of scolding or disgust, because this person may become belligerent. One priority is to find out the time of the person’s last drink and how much they drank at this episode as well as the name and amount of other drugs taken. This information will help assess any withdrawal patterns. For your own protection, be aware of hospital security or other personnel who could be called on for assistance.

Once they are sober, the hospitalised substance abuser should be assessed for the extent of the problem and the meaning of the problem for the person and family. Initially you will encounter denial and increased defensiveness; special interview techniques are needed.

Personal questions

Occasionally, people will ask you questions about your personal life or opinions, such as ‘Are you married?’, ‘Do you have children?’ or ‘Do you smoke?’ You do not need to answer every question. You may supply brief information when you feel it is appropriate, but be sensitive to the possibility that there may be a motive behind the personal questions such as loneliness or anxiety. Try directing your response back to the person’s frame of reference. You might say something like ‘No, I don’t have children; I wonder if your question is related to how I can help you care for little Jamie?’

Sexually aggressive people

On some occasions, personal questions extend to flirtatious compliments, seductive innuendo or advances. Some people experience serious or chronic illness as a threat to their self-esteem and sexual adequacy. This creates anxiety that makes them act out in sexually aggressive ways.

Your response must make it clear that you are a health professional who can best care for the person by maintaining a professional relationship. At the same time, you should communicate that you accept the person and you understand the person’s need to be self-assertive but that you cannot tolerate sexual advances. This may be difficult, considering that the person’s words or gestures may have left you shocked, embarrassed or angry. Your feelings are normal. You need to set appropriate verbal boundaries by saying, ‘I am uncomfortable when you talk to me that way; please don’t’. A further response that would open communication is: ‘I wonder if the way you’re feeling now relates to your illness or to being in the hospital?’

Crying

A beginning examiner usually feels horrified when the patient starts crying. But crying actually is a big relief to a person. Health problems come with powerful emotions. Worries about illness, death or loss take a great amount of energy to keep bottled up inside. When you say something that ‘makes the person cry’, do not think you have hurt the person. You have just hit on a topic that is important. Do not go on to a new topic. Just let the person cry and express their feelings fully. You can offer a tissue and wait until the crying subsides to talk. The person will regain control soon.

Sometimes your patient looks as if they are on the verge of tears but is trying hard to suppress them. Again instead of moving on to something new, acknowledge the expression by saying, ‘You look sad’. Do not worry that you will open an uncontrollable floodgate. The person may cry but will be relieved, and you will have gained insight to a serious concern (Case Study).

Anger

Occasionally you will try to interview a person who is already angry. Try not to personalise this anger; usually it does not relate to you. The person is showing aggression as a response to their own feelings of anxiety or helplessness. Do ask about the anger and hear the person out. Deal with the angry feelings before you ask anything else. An angry person cannot be an effective participant in a health interview.

Maybe because of an unrelated incident you are angry when you come into the interview. When you are angry, say so and tell the patient that you are angry at something or someone else. Otherwise the patient, unusually vulnerable and dependent on you, thinks you are angry at them.

Threat of violence

The healthcare setting is not immune to violent behaviour. An individual may act with such angry gestures that you feel a threat to your personal safety. Other red flag behaviours of a potentially disruptive person include fist clenching, pacing back and forth, a vacant stare, confusion, statements out of touch with reality, statements that do not make sense, a history of recent drug use (alcohol, recreational drugs) or perhaps even a recent history of intense bereavement (loss of spouse, loss of job). Trust your instincts. If you sense any suspicious or threatening behaviour, act immediately to defuse the situation. Demonstrate a sincere desire to help. Listen and offer to work with the threatening person to solve the problem. Do not raise your own voice or try to argue with them. Allow the person to set the pace. Act quite calmly and talk to the person in a soft voice. Behave in an unhurried way.

Leave the examining room door open and position yourself between the person and the door. Seek assistance promptly if the situation is escalating. Within the hospital setting, there is usually a pre-established protocol for managing threats of violence. A prearranged sign or signal is used to alert colleagues to summon security for assistance. In the community setting, systems such as emergency pager or mobile alerts may be used to summon help.

Remember that the most important goal is your personal safety so avoid taking any risks.

Anxiety

Finally, take it for granted that nearly all sick people have some anxiety. This is a normal response to being sick. It makes some people aggressive and others dependent. Remember that the person is not reacting as typically as when they are healthy.

Cultural perspectives on professional interactions

Your professional interaction depends, to a large extent, on the patient’s cultural perception of healthcare providers and the degree of formality/informality that is considered appropriate. For example, within the Australian Aboriginal population, there can be a degree of suspicion and lack of trust of the healthcare professional. This is reflective of a long-held lack of determination over their own affairs. There may be therefore a real reluctance to be forthcoming about their health status. On the other hand, some people from South-East Asian background expect those in authority, such as healthcare providers, to be authoritarian, directive and detached. In seeking healthcare, they may expect the healthcare provider to intuitively know what is wrong with them, and you may actually lose some credibility by asking a fairly standard interview question such as, ‘What brings you here?’ The person may be thinking, ‘Don’t you know why I’m here? You’re supposed to be the one with all the answers’.

Additionally, the emphasis on social harmony among certain cultures such as Asian-Australians may prevent the full expression of concerns or feelings during the interview. Such reserved behaviour may leave you with the impression that the person agrees with or understands your explanation. Nodding or smiling may only reflect their cultural value for interpersonal harmony, not agreement with you. It may also be done to ‘save face’, for when the patient is expected to understand something and does not understand, it is a ‘loss of face’ to admit this. You may distinguish between socially compliant patient responses aimed at maintaining harmony and genuine concurrence by obtaining validation of your assumptions. You might accomplish this by inviting the person to respond frankly to your suggestions or by giving the person ‘permission’ to disagree.

Etiquette

Etiquette refers to the conventional code of good manners that governs behaviour and varies cross-culturally. Consider the cultural perceptions of these different groups. Aboriginal and Torres Strait Islander people look for recognition from the healthcare professional, ‘the nurse or the doctor gotta make the first move. It is a sign of respect … to wait rather than to rush about’ (Binan Goong Aboriginal Facilitators cited in Eckermann et al, 2006: 122).

For some people from Middle Eastern and African cultures, there is a high value placed on developing interpersonal relationships and getting to know about a person’s family, personal concerns and interests before they allow you to gather personal and intimate information on their health history and to conduct a physical examination. Recognising that time constraints frequently affect the social interchange expected by individuals from some cultures, you should strive to incorporate the person’s cultural needs with the health history data categories. For example, using a conversational tone of voice, you might begin the health history by inquiring about the patient’s family members and their health. An effective way of ensuring that you capture all the important information about the patient/client in a timely manner is by using a structured assessment tool. In Australia, a ‘Culturally Inclusive Assessment Tool’ is freely available on the CEH on their website at www.ceh.org.au under Resources and Library. The assessment tool provides succinct information on what you need to assess and why.

You should be prepared for the converse when conducting the interview; that is, individuals from some cultures may want to interview you. They may ask questions about your family, marital status, salary, home address, telephone number and so forth. Your own cultural beliefs will determine your level of comfort in responding to these questions, but it is respectful to reply to some of the patient’s questions. Remember that you aren’t obliged to answer questions that you deem too personal and you always have the right to protect your personal safety. For example, you are never to provide your home address, email or telephone number. Rather, you should provide the patient with the hospital, clinic or organisation’s business number. If you want the patient to be able to contact you while you’re at home, you should ask a secretary or other third party at the healthcare facility to call your home number. You may want to consider in advance which categories of questions you are willing to discuss and which ones you will politely avoid. If you refuse to answer certain questions about yourself, remember that the person may perceive your behaviour as aloof and uncaring. Thus, the manner in which you reply to personal inquiries should be carefully worded, sensitive to the cultural needs of the patient and congruent with your own cultural beliefs.

When meeting a patient for the first time, it is best to be formal, respectful and polite. Unless a physical disability or handicap prevents you from doing so, you should be standing when you first greet the person and those accompanying them. Another aspect of etiquette concerns the use of names and titles. In order to ensure that a mutually respectful relationship is established, you should introduce yourself and indicate to the person how you prefer to be called—that is, by first name, last name and/or title. You should elicit the same information from the patient because this enables you to address the person in a manner that is culturally appropriate and could actually spare you considerable embarrassment. Everyone likes to be called by their correct name. You must be certain that you know your patients’ names, pronounce them correctly and follow cultural conventions concerning the use of titles. Avoid being unduly casual or familiar. For example, refrain from routinely using the person’s first name before you have been invited to do so. The same guidelines should be followed when addressing the family members and other visitors. It is suggested to greet the patient, ‘Hello, Mr or Mrs or Ms, my name is’ and to use your last name. The common use of ‘you guys’ and other colloquialisms must be eradicated when talking to patients and family members.

Among Chinese, Vietnamese and many other Asian groups, the family or surname is written and spoken first, followed by the first or given name. This is exactly the opposite of most European-Australian naming systems. Because politeness and formality are frequently valued by those from Asian cultures, you should address the person using the correct title (Mr, Mrs, Ms, Miss, Dr and so forth) followed by the family or surname. Be aware that some people from an Asian background, particularly those who are members of Christian religions, may also have English names. Most Asian women do not use their husband’s last name after marriage. You should be especially mindful of this when examining children in the presence of both parents. It is likely that you will need to refer to the husband and wife by different last names (e.g. Mr Cai and Mrs Li). In most Asian cultures the child is given the father’s last name. If you are in doubt, be sure to ask the patient or a significant other if the patient is unable to respond due to their condition, or has LEP.

In traditional Chinese, Japanese and other Asian cultures, when people are introduced, they show each other respect by bowing. The deeper the bow is, the more profound the respect. For example, it would be appropriate to bow very low to an older adult whose wisdom is highly regarded and less deeply to an adolescent or a young adult. With westernisation, handshakes are now customary throughout most parts of Asia and among Asian-Australians, but shaking someone’s hand too firmly or vigorously is considered rude or intrusive. Most people of Asian descent will expect you to behave in a manner congruent with your cultural heritage. In other words, it is not necessary to bow when greeting Asian-Australians but to greet them as you would other patients.

Although there are dozens of Arab (Muslim) cultures and subcultures, customs pertaining to names are similar. Both males and females are given a first name as infants. The father’s first name is used as the middle name and the last name is the family name. Some may prefer to be addressed as father (abu) or mother (um) of their oldest son (e.g. abu Walid or father of Walid). Because formality is emphasised in most Arab cultures, you should call patients Mr, Mrs, Ms, Miss or Dr followed by their last name unless invited to use more familiar first names or the abu/um form of the name. In most Arab cultures, etiquette requires either a gentle kiss on the cheeks or a handshake on arrival and departure for people of the same gender. When an Arab man is introduced to a woman, he will prefer to not be touched by her; that is, handshaking is not practised. This is done out of respect for the traditional beliefs about modesty in male–female relationships. Women may back off from strange men and not touch at all. When a handshake is not exchanged, the Muslim woman usually faces the man while bowing her head slightly and crossing her arms across her chest. In lieu of a handshake, this is a widely accepted, culturally appropriate gesture that is used when men and women are introduced in some Arab communities.

Space and distance

Both the patient’s and your own sense of spatial distance are significant throughout the interview and physical examination, with culturally appropriate distance zones varying widely. For example, you may find yourself backing away from people of Eastern European, Middle Eastern or South American origins who invade your personal space with regularity in an attempt to bring you closer into the space that is comfortable to them. Although you are uncomfortable with their close physical proximity, they are perplexed by your distancing behaviours and may perceive you as aloof and unfriendly. Summarised in Table 6.3 are the four distance zones identified for the functional use of space that are embraced by the dominant cultural group, including that of most healthcare professionals.

TABLE 6.3 Functional use of space

Source: Hall E: Proxemics: the study of man’s spatial relations. In Galdston I, editor: Man’s image in medicine and anthropology, New York, 1963, International University Press, pp. 109–120.

Cultural considerations on gender

Violating cultural norms related to appropriate male–female relationships may jeopardise your professional relationship with many patients. Among some Arab (Muslim) cultures, you may find that an adult male is never alone with a female (except his wife) and is generally accompanied by one or more other males when interacting with females. This behaviour is culturally very significant; failure to adhere to the cultural code (set of rules or norms of behaviour used by a cultural group to guide their behaviour and interpret situations) is viewed as a serious transgression, often one in which the lone male will be accused of sexual impropriety. The best way to ensure that cultural variables have been considered is to ask the person about culturally relevant aspects of male–female relationships, preferably at the beginning of the interview—before you have an opportunity to violate any culturally based practices. When you have determined that gender differences are important to the patient, you might try strategies such as offering to have a third person present when this is feasible. If a family member or friend has accompanied the patient, you might inquire whether the patient would like that person to be in the examination room during the history and/or physical examination. It is not unusual for a female to refuse to be examined by a male and vice versa. Modesty is another issue and it is imperative to ensure that the patient is carefully draped at all times, that curtains are closed and, when possible, doors should also be closed. A room must not be entered without knocking first and announcing yourself.

The gender issue is further complicated by cultural beliefs about relationships with authority figures and cross-national perspectives on the status of various healthcare disciplines. For example, in many less developed nations, nursing is a low-status occupation. In some oil-rich Arab countries (e.g. Saudi Arabia, Kuwait), care for the sick is carried out by healthcare providers who are hired from abroad for the purpose of caring for the bodily needs of the sick, an activity that is considered undignified.

Cultural considerations on sexual orientation

In approaching lesbian, gay or bisexual individuals, you should be aware of heterosexist biases and the communication of these biases during the interview and physical examination. Heterosexism refers to the institutionalised belief that heterosexuality is the only natural choice and assumes it is the norm. For example, most health histories include a question concerning marital status. Although many same-sex couples are in committed, long-term monogamous relationships, seldom is there a category on the standard form that acknowledges this type of relationship. Although technically and legally the person may be single, this trivialises the relationship with their significant other. It also may have health-related implications if the person is diagnosed, for example, with a communicable disease, which may range in severity from a minor sore throat to a life-threatening condition such as HIV/AIDS. In extreme cases, lesbians have been subjected to unnecessary diagnostic procedures when the heterosexual assumption was made.

Working with (and without) an interpreter

Approximately 3 million people in Australia speak a non-English language at home. Speakers of Indigenous languages numbered 50 000 and comprised 1.7% of all non-English speakers (Australian Bureau of Statistics (ABS), 2006). One of the greatest challenges in cross-cultural communication occurs when you and the patient speak different languages (Fig 6.5). After assessing the language skills of non-English-speaking people, you may find yourself in one of two situations: trying to communicate effectively through an interpreter or trying to communicate effectively when there is no interpreter.

Figure 6.5

Interviewing the non-English-speaking person requires a bilingual interpreter for full communication. Even the person from another culture or country who has a basic command of English (those for whom English is a second language) may need an interpreter when faced with the anxiety-provoking situation of entering a hospital, describing a strange symptom or discussing sensitive topics such as those related to reproductive or urological concerns.

It is tempting to ask a relative, friend or even another patient to interpret because this person is readily available and probably would like to help. This is disadvantageous because it violates confidentiality for the patient, who may not want personal information shared with another. Furthermore, the friend or relative, although fluent in ordinary language usage, is likely to be unfamiliar with medical terminology, hospital or clinic procedures and medical ethics.

Whenever possible, work with a bilingual team member or a trained medical interpreter. This person knows interpreting techniques, has a healthcare background and understands patients’ rights. The trained interpreter is also knowledgeable about cultural beliefs and health practices. This person can help you bridge the cultural gap and can advise you concerning the cultural appropriateness of your recommendations.

Although interpreters are trained to remain neutral, they can influence both the content of information exchanged and the nature of the interaction. Many trained medical interpreters are members of the linguistic community they serve. While this is largely beneficial, it has limitations. For example, interpreters often know patients and details of their circumstances before the interview begins. Although acceptance of a code of ethics governing confidentiality and conflicts of interest is part of the training interpreters receive, discord may arise when they relate information that the patient has not volunteered to the examiner.

It should be noted that being bilingual doesn’t always mean the interpreter is culturally aware. Australian Aboriginal culture, for example, is so diverse that an Indigenous interpreter from one region doesn’t necessarily understand the cultural background of an Indigenous person from another region. Even trained interpreters, who are often from urban areas and represent a higher socioeconomic class than the patients for whom they interpret, may be unaware of or embarrassed by rural attitudes and practices.

Although you will be in charge of the focus and flow of the interview, view yourself and the interpreters as a team. Ask the interpreter to meet the patient beforehand to establish rapport and to garner the patient’s age, occupation, educational level and attitude towards healthcare. This enables the interpreter to communicate on the patient’s level.

Allow more time for this interview. With the third person repeating everything, it can take considerably longer than interviewing English-speaking people. You need to focus on priority data.

There are two styles of interpreting—line-by-line and summarising. Translating line-by-line takes more time, but it ensures accuracy. Use this style for most of the interview. Both you and the patient should speak only a sentence or two, then allow the interpreter some time. Use simple language yourself, not medical jargon that the interpreter must simplify before it can be translated. Summary translation progresses faster and is useful for teaching relatively simple health techniques with which the interpreter is already familiar. Be alert for nonverbal cues as the patient talks. These cues can give valuable data. A good interpreter also notes nonverbal messages and passes them on to you. Summarised in Table 6.4 are suggestions for the selection and use of an interpreter.

TABLE 6.4 Use of an interpreter

Although use of an interpreter is the ideal, you may find yourself in a situation with a non-English-speaking patient when no interpreter is available. Table 6.5 summarises some suggestions for overcoming language barriers when no interpreter is present. Communicating with these patients may require that you combine verbal and nonverbal communication.

TABLE 6.5 Overcoming language barriers: What to do when no interpreter is available

Nonverbal cross-cultural communication

Basically, there are five types of nonverbal behaviours that convey information about the person: (1) vocal cues, such as pitch, tone and quality of voice, including moaning, crying and groaning; (2) action cues, such as posture, facial expression and gestures; (3) object cues, such as clothes, jewellery and hair styles: (4) use of personal and territorial space in interpersonal transactions and care of belongings; and (5) touch, which involves the use of personal space and action (Lapierre and Padgett, 1991).

Unless you make an effort to understand the patient’s nonverbal behaviour, you may overlook important information such as that conveyed by facial expressions, silence, eye contact, touch and other body language. Communication patterns vary widely transculturally even for such conventional social behaviours as smiling and handshaking. Among many Hispanic people, for example, smiling and handshaking are considered an integral part of sincere interactions and essential to establishing trust, whereas a Russian person might perceive the same behaviour as insolent and frivolous.

In Aboriginal culture, the unspoken messages given and received have the greatest impact on communication. ‘We take our cues from the other person’ (Eckermann et al 2006: 119). Wide cultural variation exists when interpreting silence. Some individuals find silence extremely uncomfortable and make every effort to fill conversational lags with words. A pause following your question signifies that what has been asked is important enough to be given thoughtful consideration. For example, in traditional Chinese and Japanese cultures, silence may mean that the speaker wishes the listener to consider the content of what has been said before continuing. People from English and Arabic backgrounds may use silence out of respect for another’s privacy, whereas those who are French, Spanish or Russian may interpret it as a sign of agreement. Asian cultures often use silence to demonstrate respect for elders.

Eye contact is perhaps among the most culturally variable nonverbal behaviours. Although you probably have been taught to maintain eye contact when speaking with others, individuals from culturally diverse backgrounds may attribute other culturally based meanings to this behaviour. In some cultures modesty for both women and men is interrelated with eye contact. For example, for some Muslim-Arab women, modesty is achieved in part by avoiding eye contact with males (except for one’s husband in private settings) and keeping the eyes downcast when encountering members of the opposite gender in public situations.

Touch

Without doubt, touching the patient is a necessary component of a comprehensive assessment. From a cultural perspective, however, you are urged to give careful consideration to issues concerning touch. While recognising the benefits reported by many in establishing rapport with patients through touch, physical contact with patients conveys various meanings cross-culturally. In many cultures, adolescent girls may prefer female healthcare providers or refuse to be examined by a male. You should be aware that the patient’s significant others also may exert pressure on nurses by enforcing these culturally meaningful norms in the healthcare setting.

Touching children may also have associated meaning transculturally. For example, some Asian people believe that one’s strength resides in the head and that touching the head is a sign of disrespect. The clinical significance of this is that you need to be aware that patting the child on the head or examining the fontanelle, for example, should be avoided or done only with parental permission. Whenever possible, you should explore alternative ways to express affection or to obtain information necessary for assessment of the patient’s condition (e.g. hold the child on the lap, observe for other manifestations of increased intracranial pressure or signs of premature fontanelle closure, or place one’s hand over the mother’s while asking for a description of what she feels).

Always remember that because patients come from a diversity of cultural backgrounds, some of which are not always obvious, it is important to conduct the interview with an open mind and accepting attitude for each individual person.